OF mental health care and mentally ill

Violence and mental disorder

While public prejudice, backed up at times by the views of politicians simply assumes that mental disorder predicts violence to others, the considered empirical position about this relationship has varied over time. Broadly three phases can be identified:

1 The negative relationship phase. Studies of the relationship between mental disorder and violence between 1925 and 1965 suggested that people with mental health problems were actually less violent than the general population (Rabkin 1979). \

2 The small positive relationship phase. After 1965 this position went into reverse. Link et al. (1992) found that after 1965 the median ratio was one of 3:1, with patients being more violent than non-patients. A number of factors could account for this reversal.

First, episodic violent acts were historically contained in mental hospitals, when nearly all patients where chronically warehoused, with the range of potential victims being highly restricted in closed settings. This changed as more and more patients were treated in the community.

Second, the community settings for patients were often risky environments–poor and socially disorganized with high rates of crime.

Third, these environments also contained access to substances which could be abused less readily in hospital settings. Reviewing this small positive relationship, Monahan (1992: 510) noted that: None of the data give any support to the sensationalized caricature of the mentally disordered served up by the media … Compared with the magnitude of risk associated with the combination of male gender, young age, and lower socio-economic status for example, the risk of violence presented by mental disorder is modest. Compared with the magnitude of risk associated with alcoholism and other drug abuse, the risk associated with major mental disorders such as schizophrenia and affective disorder is modest indeed. Clearly, mental health status makes at best a trivial contribution to the overall level of violence in society.

3 The disaggregated data phase. During the 1990s a further analysis of the small relationship revealed a complicated inter-relationship between clinical factors, personality factors and contextual factors (Blumenthal and Lavender 2000; Pilgrim and Rogers 2003). An increasing number of studies began to address specific aspects of the relationship between mental state and violence. The following summarizes these findings:

•Ambiguous findings have been evident about the link between psychosis alone and violence in community settings. Swanson et al. (1990) found that psychotic patients who did not abuse substances were three times more dangerous than their non-patient equivalents over a period of a year. By contrast Steadman et al. (1998) found that psychotic patients who did not abuse substances were no more likely to be violent than their neighbours. Given that violent acts are quite rare it is also worth noting that even in the Swanson et al. study, their findings only pointed up 7 per cent of violent compared to 93 per cent non-violent patients. This is why the summary of the small aggregate relationship by Monahan above refers to a ‘trivial contribution’.

•Substance abuse predicts violence. People, whatever their mental state, who abuse alcohol and some other substances (such as crack cocaine) are significantly prone to violence and other risky behaviour, such as dangerous driving. Some drugs do not predict violence though, most notably the opiates (though they do predict other forms of criminality to feed the habit). Substance abuse also is the best predictor of violence in psychotic patients (Steadman et al. 1998).

•The diagnosis of mental disorder which best predicts violence is that of a type of personality disorder (anti-social/dissocial/psychopathic). This is hardly surprising. As we noted earlier this diagnosis is typically defined tautologically by persistent violent habits. Broad diagnoses alone of mental disorder (such as personality disorder in general) or mental illnesses such as ‘schizophrenia’ are very poor predictors of violence.

•Ambiguous findings exist about the role of individual symptom and treatment variables. For example, compliance with medication reduces the risk of violence (Swartz et al. 1998). Command hallucinations with hostile content predict violent acts (Junginger 1995). Taylor (1985) also found that this was the case for hostile delusions. However, other studies have not demonstrated a relationship between hallucinations or delusions and violence (Teplin et al. 1994; Appelbaum et al. 1999; 2000). Violent ruminations seem to predict violence in those who abuse substances (Grisso et al. 2000). Indeed the consistent theme in the recent literature is that psychopathic disorder and substance misuse are strong predictors of violence but psychosis per se is not.

•Independent of clinical and personality variables, some times and places shape dangerousness more than others. When patients are discharged into richer areas they are less dangerous than in poorer areas (Silver et al. 1999). The latter areas of ‘concentrated poverty’ contain what Hiday (1995) calls ‘violence inducing social forces’. In these poor community contexts, patients are more prone to be both the victim and perpetrator of crimes.

Having summarized the phases of empirical investigation about the overall or aggregate link between mental state and violence a prospective question is begged: can violence be predicted in individual cases? A number of criticisms can be raised in relation to the possibility:

1 The empirical attack. This is a body of research evidence which suggests that accurate prediction is impossible: ‘It now seems beyond dispute that mental health professionals have no expertise in predicting future dangerous behaviour either to self or others. In fact predictions of dangerous behaviour are wrong about 90 per cent of the time’ (Ennis and Emery 1978: 28).

2 The political attack. From a libertarian position, Szasz (1963: 46) has argued that prediction violates patients’ civil rights: Drunken drivers are dangerous both to themselves and to others. They injure and kill many more people than, for example persons with paranoid delusions of persecution. Yet, people labelled ‘paranoid’ are readily committable, while drunken drivers are not … Some types of dangerous behaviour are even rewarded. Racecar drivers, trapeze artists, and astronauts receive admiration and applause …

Thus, it is not dangerousness in general that is at issue here, but rather the manner in which one is dangerous. The libertarian critique from Szasz has been echoed by other critics (e.g. Sayce 2000) who have argued that singling out mentally disordered indi viduals for particular scrutiny in relation to dangerousness is discriminatory. This point can be highlighted by the use of a table (Table 10.1) which identif ies the contingent judgments and outcomes applying to a variety of social groups.

3 Professional dissent. The third source of attack emanates from some mental health professionals. Because predicting dangerousness is tied to social control, some professionals worry that it is incompatible with a caring and therapeutic role. They resent and resist becoming society’s police officers for informal rule rather than law infringement. Risk minimization pushes professionals into conservative decision making to avoid false negatives (predicting the absence of risk when a patient then goes on to be dangerous). T

his type of decision making encourages professionals to take a distrusting attitude towards patients in general. The discussion earlier about the way in which legal rules and obligations interfere with professional ethos of care is relevant to this point. These various examples demonstrate that psychiatric patients are only one of many groups that we might consider when thinking about degrees of dangerousness and socio-legal sanction. The question is whether or not psychiatric patients are offered the same rights as others in the table. For instance, currently in Britain people of known dangerousness (like those in cells 4 and 6) are morally condemned but not legally restrained. By contrast, many psychiatric patients who are no proven threat to others are compulsorily detained under the Mental Health Act.